Pediatrix

This child qualifies for vaccination through the VCF program because he/she is age birth-17 and is:

Please be advised, if your insurance company does not cover immunizations and you do not let Pediatrix know at the time of your visit, it is your responsibility to pay the full vaccine cost. Pediatrix cannot make the Vaccine for Children Program retroactive and you are only eligible for the Vaccine for Children Program at the time of the visit. If you are unsure if immunizations and well-checks are covered please contact your insurance company.

I have been provided a copy of the appropriate Centers for Disease Control and Prevention Vaccine Information Sheet(s) and have read, or have had explained to me, information about the diseases and vaccines listed below. I have had a chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks of the vaccines cited, and ask that the vaccine(s) listed below (including any appropriate combinations vaccines) be given to me or the person named above, for whom I am authorized to make this request.